An evaluation of hernia education in surgical residency programs

PURPOSE

The purpose of this study was to evaluate surgical residents' educational experience related to ventral hernias.

METHODS

A 16-question survey was sent to all program coordinators to distribute to their residents. Consent was obtained following a short introduction of the purpose of the survey. Comparisons based on training level were made using χ(2) test of independence, Fisher's exact, and Fisher's exact with Monte Carlo estimate as appropriate. A p value <0.05 was considered significant.

RESULTS

The survey was returned by 183 residents from 250 surgical programs. Resident postgraduate year (PG-Y) level was equivalent among groups. Preferred techniques for open ventral hernia varied; the most common (32 %) was intra-abdominal placement of mesh with defect closure. Twenty-two percent of residents had not heard of the retrorectus technique for hernia repair, 48 % had not performed the operation, and 60 % were somewhat comfortable with and knew the general categories of mesh prosthetics products. Mesh choices, biologic and synthetic, varied among the different products. The most common type of hernia education was teaching in the operating room in 87 %, didactic lecture 69 %, and discussion at journal club 45 %. Number of procedures, comfort level with open and laparoscopic techniques, indications for mesh use and technique, familiarity and use of retrorectus repair, and type of hernia education varied significantly based on resident level (p < 0.05).

CONCLUSION

Exposure to hernia techniques and mesh prosthetics in surgical residency programs appears to vary. Further evaluation is needed and may help in standardizing curriculums for hernia repair for surgical residents.

Hernia recurrence through a composite mesh secondary to transfascial suture holes

Laparoscopic ventral hernia repair is an accepted method for incisional hernia repair. Although techniques vary, transfascial suturing of the mesh to the abdominal wall has been proposed as a viable way to fixate the mesh and reduce recurrence rates. We report a 54-year-old woman who had previously undergone a laparoscopic ventral hernia repair following a laparoscopic tubal ligation using a Composix mesh. The patient presented with a symptomatic hernia recurrence. The computed tomography scan showed a periumbilical hernia containing fat. The patient underwent diagnostic laparoscopy and lysis of adhesions. During the lysis of adhesions, a recurrence through the previously placed composite mesh was encountered where holes had been made by the previously placed transfascial sutures. The hernia was reduced, mesh was removed, and an ePTFE mesh was used to repair the hernia. The mechanism of recurrence appeared to be improperly placed transfascial sutures; overly large bites of mesh caused excessive tension and ultimately a hole in the mesh. Hernia recurrence due to mesh or transfascial suture failure is rarely reported and most often caused by inadequate fixation. Our case highlights the need for meticulous placement of transfascial sutures and demonstrates a mechanism of recurrence due to inadequate placement.

A statewide analysis of level I and II trauma centers for patients with major injuries

BACKGROUND

This study examines statewide outcomes and resource use in Level I and II trauma centers for patients with major injuries.

METHODS

This study analyzed trauma registry data on patients admitted to North Carolina Level I and II trauma centers from January 1995 to December 1996 with one of four major injuries: thoracic aortic disruption, liver injury, pelvic fracture, or pulmonary contusion.

RESULTS

There were 59 thoracic aortic disruptions, 109 liver injuries, 153 pelvic fractures, and 962 pulmonary contusions identified among 26,030 admissions. Case fatality was not significantly different (Level I, 16.8%; Level II, 14.9%). Hospital charges were significantly higher in Level I centers (Level I, $47,366; Level II, $35,490), but this difference was confined to transferred patients. Controlling for Revised Trauma Score, Injury Severity Score, age, gender, and race, multivariable regression confirmed findings regarding hospital charges, and multiple logistic regression confirmed findings regarding case fatality.

CONCLUSION

Case fatality was similar in Level I and Level II trauma centers in North Carolina, and hospital charges were comparable in patients with comparable injuries not requiring transfer. This suggests that patients with major injuries may be optimally cared for in both Level I and Level II trauma centers.

A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene

INTRODUCTION

Comprehensive emergency medical services and helicopter aeromedical transport systems have been developed based on the principle that early definitive care improves outcome. The purpose of this study was to compare outcomes between patients transported by helicopter and those transported by ground.

METHODS

Data were obtained from the North Carolina Trauma Registry for the period between 1987 and 1993 on all patients transported by helicopter and ground admitted to one of the eight state designated trauma centers. Study patients included only those who were transported directly from the scene of injury to the trauma center (interhospital transfers were excluded). Mortality (outcome) was compared after patient stratification by injury severity and transport time, using Cochran-Mantel-Haenszel statistics and logistic regression-derived probabilities of survival.

RESULTS

One thousand three hundred forty-six patients (7.3% of the total) were transported from scene to trauma center by helicopter and 17,144 were transported by ground. In patients transported by helicopter, the mean Trauma Score was lower (12 +/- 3.6) versus 14.3 +/- 3.6 (p < 0.001) and the mean Injury Severity Score was higher (17 +/- 11.1) versus 10.8 +/- 8.4 (p < 0.001). A trend toward increased survival was observed among patients transported by helicopter with a higher Injury Severity Score. Statistical significance was achieved only for patients with a Trauma Score between 5 and 12 and Injury Severity Score between 21 and 30.

CONCLUSION

The large majority of trauma patients transported by both helicopter and ground ambulance have low injury severity measures. Outcomes were not uniformly better among patients transported by helicopter. Only a very small subset of patients transported by helicopter appear to have any chance of improved survival based on their helicopter transport. This study suggests that further effort should be expended to try to better identify patients who may benefit from this expensive and risky mode of transport.

A statewide, hospital-based analysis of frequency and outcomes in carotid endarterectomy

BACKGROUND

For more than 40 years carotid endarterectomy (CE) has been used in the treatment of extracranial carotid disease for the prevention of stroke. Recent prospective clinical trials have confirmed the benefit of CE for both symptomatic and asymptomatic patients. Our purpose was to examine statewide trends in the numbers of CE over a 6-year time period and to evaluate outcomes.

METHODS

Using data from the North Carolina Medical Database Commission (NCMDC) all CE procedures from 1988 to 1993 were identified. Numbers of CE were compared with the population and hospital admissions. Variables of length of stay, hospital charges, discharge disposition, and occurrence of stroke and death were analyzed.

RESULTS

A total of 11,973 CE were performed in 6 years. Compared by admissions, population, and the proportion of elderly, the number of CE increased yearly. The stroke rate was 1.7% and the death rate 1.2% for an overall in-hospital stroke plus mortality rate of only 2.7%.

CONCLUSIONS

From a diverse group of hospitals and a large number of surgeons and patients, this hospital-based study documents the acceptance and safety of CE in the treatment of extracranial carotid disease.

Management outcomes in splenic injury: a statewide trauma center review

OBJECTIVE

Clinical pathways now highlight both observation and operation as acceptable initial therapeutic options for the management of patients with splenic injury. The purpose of this study was to evaluate treatment trends for splenic injury in all North Carolina trauma centers over a 6-year period.

METHODS

Splenic injuries in adults over a 6-year period (January 1988-December 1993) were identified in the North Carolina Trauma Registry using ICD-9-CM codes. Patients were divided into four groups by method of management: 1) no spleen operation, 2) splenectomy, 3) definitive splenorrhaphy, and 4) splenorrhaphy failure followed by splenectomy. The authors examined age, mechanism of injury, admitting blood pressure, and severity of injury by trauma score and injury severity score.

SUMMARY BACKGROUND DATA

Comparisons were made between adult (17-64 years of age) and geriatric (older than 65 years of age) patients and between patients with blunt and penetrating injury. Resource utilization (length of stay, hospital charges) and outcome (mortality) were compared.

RESULTS

One thousand two hundred fifty-five patients were identified with splenic injury. Rate of splenic preservation increased over time and was achieved in more than 50% of patients through nonoperative management (40%) and splenorrhaphy (12%). Splenorrhaphy was not used commonly in either blunt or penetrating injury. Overall mortality was 13%. Geriatric patients had a higher mortality and resource utilization regardless of their mechanism of injury or method of management.

CONCLUSIONS

Nonoperative management represents the prevailing method of splenic preservation in both the adult and geriatric population in North Carolina trauma center hospitals. Satisfactory outcomes and economic advantages accompany nonoperative management in this adult population.

Splenic salvage in adults at a level II community hospital trauma center

Recognition of the important role of the spleen within the immune system has prompted surgeons to regularly consider splenic preservation. We studied our experience at a Level II trauma center to determine whether this trend is reflected in our management. We reviewed 81 adult blunt trauma patients with splenic injury admitted between January 1988 and December 1993. We examined age, race, and clinical data including mechanism of injury, trauma and injury severity scores, organ injury scale (OIS) grade, admitting blood pressure, operations, length of stay, hospital charges, and outcome. Thirty-nine patients underwent immediate splenectomy. Nonoperative treatment was successful in 31 of 37 patients (83.7%). Mean OIS grade (American Association for the Surgery of Trauma) was significantly different between patients treated nonoperatively (1.6 +/- 0.9) and patients treated with immediate splenectomy (3.9 +/- 1.1), (P = <0.001). American Association for the Surgery of Trauma OIS grade correlated well between CT classification and classification at operation (r = 0.7, P = 0.0001) but did not predict success in nonoperative management. Hemodynamic stability, injury severity, and abdominal CT scan findings determine choice of therapy. Splenorrhaphy is frequently discussed but infrequently performed. Splenectomy remains the most commonly performed operation for splenic injury in adults with blunt splenic trauma. Nonoperative management is the most common method of splenic salvage at the Level II community hospital trauma center.

Thoracic aorta injuries: management and outcome of 144 patients

Rupture of the thoracic aorta from blunt injury is often lethal. Methods of operative repair vary, based on the surgeon's preference and circumstances. The primary hypothesis of this study was that operative management choices would correlate with outcome. Data on demographics, injury mechanism, initial evaluation, diagnostic procedures, operative treatment, and outcome were obtained from chart review at the state's eight trauma centers. Rates of paraplegia and survival were compared for different methods of operative repair. Of 63,507 hospitalized trauma patients, 144 patients sustained thoracic aortic injury (incidence = 0.23%). Sixty-four died (44.1%), most of whom died in the emergency department (26) or the operating room (12). Eighty-six patients had complete operative data for analysis, including cross-clamp time and methods of repair. No patient in the group with a cross-clamp time of less than 35 minutes developed paraplegia (p = 0.02). For the patients with longer cross-clamp times, 6 of 14 patients (42.9%) undergoing clamp and sew repair developed paraplegia, as compared to 2 of 37 patients (5.4%) repaired on bypass (p = 0.005). This study suggests that the rate of paraplegia after repair of thoracic aortic injury can be minimized with short cross-clamp times or the use of bypass when long cross-clamp times can be anticipated.

Poor hospital documentation of violence against women

OBJECTIVE

This study sought to determine if violence against women is accurately documented in the trauma registry, and if poor documentation in the medical record is associated with incorrect coding in the registry.

DESIGN

Retrospective cohort study.

MATERIALS AND METHODS

We identified women aged 15 to 49 in the trauma registry of a regional medical center who had unintentional and intentional injuries over three years, and retrospectively reviewed their medical records to verify registry coding.

MEASUREMENTS AND MAIN RESULTS

Of the 41 assault victims in the registry, 32 were verified by the medical record. Of the 87 unintentional injuries, only 28 were verified; 21 were assault victims according to the medical record, and for the remaining 38, the medical record was too vague to determine intentionality. Thus, the sensitivity of the trauma registry in documenting violence against women was only 57%. Injuries correctly coded in the registry had the details well documented in the medical record, whereas injuries incorrectly coded had poor documentation in the medical record.

CONCLUSIONS

Violence against women often goes undocumented in hospital data systems.

Laparoscopic excision of a benign gastric tumor

A successful laparoendoscopic excision of a 3-cm leiomyoma of the stomach is reported. Review of related literature and suggested technique and methods for this procedure are described.

The financial impact of intentional violence on community hospitals

The purpose of this study was to examine the financial impact of assault-related penetrating trauma. We specifically reviewed hospital charges and reimbursement data. Two hundred eleven patients were identified from our Trauma Registry in a 4-year period: 108 with firearm injuries and 103 with injuries related to cutting or piercing instruments. Assault-related penetrating injuries generated more than $2,000,000 in hospital charges. Sixty-seven percent of this amount was incurred by patients who had no source of third-party payment. Reimbursement covered only 30% of charges. There were no differences in demographics, procedures, or in insurance status, mean charges, and unpaid balances between patients directly admitted and those transferred from other hospitals. Financial losses incurred by community hospitals from the care of penetrating injuries are substantial, and must be borne by cost shifting or other strategies. No evidence of "dumping" was found among this group of patients. The specter of injury caused by intentional violence extends beyond urban trauma centers, and has a serious negative financial impact on community trauma centers.

Oral contrast is not necessary in the evaluation of blunt abdominal trauma by computed tomography

The administration of oral contrast (OC) is widely recommended for computed tomography (CT) of the abdomen in patients with blunt trauma. The purpose of this study was to determine whether routine abdominal CT scans performed without OC were associated with diagnostic error in patients with blunt trauma. Four hundred ninety-two patients were identified from our Trauma Registry who had CT scans for the evaluation of blunt abdominal trauma between January 1988 and December 1991. Seventy-six percent (372) of the CT scans were interpreted as negative, and 24% (120) were considered positive. OC was used in 8 (1.6%) of 492 patients. Only 1 of 372 patients whose initial non-OC--enhanced scan was negative subsequently required surgery. There were 5 bowel injuries among the 42 patients who underwent an abdominal operation; in none would the use of OC have ensured the preoperative diagnosis. We found that the omission of OC did not represent a disadvantage to patients with blunt trauma undergoing a routine abdominal CT scan. Potential time delays and the hazards associated with the use of OC were minimized.

Hospital resources used to treat the injured elderly at North Carolina trauma centers

OBJECTIVE

The purpose of this paper is to compare the hospital resources used by elderly, adult, and pediatric patients treated in hospitals reporting to the North Carolina Trauma Registry (NCTR).

DESIGN

We analyzed data on all patients entered into the NCTR from 1 January 1988 to 31 December 1990.

SETTING

The NCTR is a statewide registry of all trauma patients admitted for at least 24 hours or dead on arrival at the eight Level I and II trauma center hospitals in North Carolina.

PATIENTS

The total number of patients included in the study was 21,214; elderly adults included those age 65 and older (n = 2808), adults included those 15 to 64 years old (n = 15,776), and pediatric patients included those 0 to 14 years old (n = 2630).

MAIN OUTCOME MEASURES

We examined hospital resources using three measures: overall length of hospital stay in days, intensive care unit (ICU) length of stay in days for those admitted to the ICU, and total hospital charges billed during the hospitalization.

RESULTS

Controlling for injury severity, we found that elderly adults had longer mean hospital and ICU lengths of stay and higher mean hospital charges than adults or children. Whereas only 22% of injuries to elderly adults were transportation-related, transportation injuries generated 38% of their hospital charges. Sixty-eight percent of their injuries were caused by falls, generating total hospital charges of $17.6 million, an average of 15 days in hospital stay and 9 days in ICU stay.

CONCLUSION

A 10% reduction in both transportation injuries and falls among the elderly could save $3.5 million in this population over 3 years.

Immediate isolated interventricular septal defect from nonpenetrating thoracic trauma

Interventricular septal defect following nonpenetrating trauma is a rare event. In a review of 207,548 autopsies, only 30 (0.01%) cases of traumatic ventricular septal defects were noted, and only 5 (0.002%) were isolated. We report an isolated interventricular septal defect following nonpenetrating trauma.

Laparoscopic cholecystectomy in situs inversus totalis

A 51-year-old woman with known dextrocardia presented with left-sided abdominal pain and symptoms consistent with biliary colic and cholelithiasis. Abdominal ultrasound confirmed the diagnosis of gallstones, as well as situs inversus with the liver and gallbladder on the left side and the spleen on the right. Laparoscopic cholecystectomy was performed without incident. The procedure was uncomplicated except for being the mirror image of that done with the gallbladder in the normal location. Cholelithiasis occurring with situs inversus is rare and may present a diagnostic problem. The extrahepatic anatomy of the biliary and venous system is the mirror image of the right sided liver. Historic and genetic aspects of situs inversus, as well as current theories regarding its etiology are presented. Situs inversus totalis does not appear to be a contraindication to laparoscopic treatment of cholelithiasis.

Results of staged bilateral carotid endarterectomy

To determine differences in outcome between unilateral and staged bilateral carotid endarterectomies, we reviewed 850 carotid endarterectomies done by 14 surgeons in a community hospital. Results of 528 unilateral procedures were compared with those of 161 bilateral procedures. Data were abstracted from records for an 11-year period. Twelve of the patients in the unilateral group had nonfatal strokes, and 14 died within 30 days of surgery (stroke + death rate, 4.9%). There were no nonfatal strokes among patients in the bilateral group, and nine died (stroke + death rate, 5.6%). Seven of 14 deaths in the unilateral group and six of nine deaths in the bilateral group were due to neurologic events. In the bilateral group, death was associated with postoperative hypertension and a short intersurgical interval. The stroke + death rate was not significantly different between unilateral and bilateral procedures and compared favorably with North American Symptomatic Carotid Endarterectomy Trial guidelines and other published reports. Staged bilateral carotid endarterectomy can be safely performed in a community hospital.

Cardiac output measurement in critical care patients: Thoracic Electrical Bioimpedance versus thermodilution

Thoracic Electrical Bioimpedance (TEB) is a method for measuring cardiac performance which is noninvasive, continuous, has minimal technical requirements, and no patient risk. We used a commercially available TEB device to measure cardiac output in patients with thermodilution catheters in place. We compared the cardiac output measurements for the two modalities. We also compared the average hospital cost for initial cardiac assessment using the two techniques. The mean difference between the two cardiac output measurements was small (0.23 +/- 0.56) and not affected by the magnitude of the cardiac output readings. There was a strong correlation between COTD and COTEB (r = 0.91) and the regression slope was 0.91 with a Y intercept of 0.76. Cost analysis demonstrated that the use of TEB was approximately $600 less than thermodilution. Thoracic electrical bioimpedance measurement of cardiac output may offer a valuable alternative to the invasive measurement of the thermodilution catheter.

Mirizzi's syndrome: a contraindication to coelioscopic cholecystectomy

An impacted gallstone in the cystic duct with subsequent inflammation and edema resulting in extrinsic compression of the common bile or common hepatic duct with obstructive jaundice is known as Mirizzi's syndrome. An uncommon complication of cholelithiasis, Mirizzi's syndrome should be included in the differential diagnosis of any patient who has extrahepatic biliary obstruction. We present a case of a patient who underwent open rather than coelioscopic cholecystectomy based upon the preoperative diagnosis of Mirizzi's syndrome. A multidisciplinary approach to such patients facilitates the decision between open and endoscopic cholecystectomy. Mirizzi's syndrome may represent a contraindication to endoscopic cholecystectomy.

Patient awareness of health precautions after splenectomy

Sepsis after splenectomy is a lifelong risk, and patients who have had splenectomy should be educated about this risk. This study examines patient knowledge after splenectomy. We reviewed hospital records of 118 patients who had splenectomies performed between 1982 and 1988 at New Hanover Memorial Hospital. Twenty-four patients have died since their surgery; one death was suspected to be due to postsplenectomy sepsis. Of the 89 patients alive and eligible for follow-up, we were able to query 63. Only 16% were aware of any health precautions. After prompting, patient awareness improved to 40%. We also surveyed 11 of the 14 surgeons who performed the splenectomies. They indicated that they always discuss with their patients the immunologic consequences of spleen removal and the increased risks of infection, although they do not always recommend pneumococcal vaccine. We conclude that splenectomy patients have a low level of knowledge about postsplenectomy infection risks and precautions. We developed an educational pamphlet to aid the surgeon in patient education.

Community hospital carotid endarterectomy in patients over age 75

We compared the prevalence of stroke and death in 133 patients aged 75 and older in whom 170 carotid endarterectomies were performed with that in 501 patients less than age 75 in whom 640 carotid endarterectomies were performed. There were three strokes (2%) in patients aged 75 and older and nine strokes (1%) in younger patients (p = 0.7). There were 8 deaths (5%) in patients aged 75 and older and 14 deaths (2%) in younger patients (p = 0.1). After controlling for the possible confounding effects of diabetes, prior stroke, history of angina, prior carotid artery disease, previous vascular surgery, history of myocardial infarction, preoperative hypertension requiring medication, and female gender, a logistic regression model showed that patients aged 75 and older were no more likely to have a stroke or death than patients under age 75. We conclude that age alone is not a contraindication to the safe performance of carotid endarterectomy in the community hospital.

Infrequency of blacks among patients having carotid endarterectomy

We reviewed demographic data on patients having 2,256 carotid endarterectomies in eight large hospitals in North Carolina to determine the frequency of blacks among these patients. Blacks comprised only 4.6% of the patients having carotid endarterectomy even though they comprised 26% of all patients discharged and 22% of the general population of the state. Data from the National Inpatient Profile of the Commission on Professional and Hospital Activities, which represents patients discharged from short-term, nonfederal hospitals throughout the United States, show that nationwide, blacks comprise only 2.7% of the patients having carotid endarterectomy, whereas they comprise 12.0% of all patients discharged, 12.1% of the general population, and 10.7% of patients discharged following Class I surgical procedures. Blacks have only 67 carotid endarterectomies per 100,000 patients discharged; this rate is five or more times higher in whites. Among black patients having carotid endarterectomy, women predominate, whereas men predominate among white patients having carotid endarterectomy (p = 0.006). The underrepresentation of blacks among patients having carotid endarterectomy lends support to the concept that carotid vascular disease in blacks is distributed intracranially rather than extracranially as opposed to the extracranial rather than intracranial distribution in whites.